Child Registration Form

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Child Registration

TRINITY PSYCH WELLNESS


Person Completing This Form

Provide your details.


CHILD'S INFORMATION


CONTACT INFORMATION

Provide phone numbers where we may contact or leave a message.


1. Contact

Main person to contact


2. Contact

Second contact


3. Emergency Contact

In case of an emergency, if the above two contacts cannot be reached.


Financial Contact

The person responsible for the child's therapy service or financial agreement.


FAMILY HISTORY

Details about the child's family.


RELATED TO PARENT'S DIVORCE

A copy of court documents is required and will be a part of the child's file.


HOUSEHOLD MEMBERS

List all children and adults who live in the child's home. Add a new line for each member.
Please include: name, age, sex, and relationship to child. Example:
Bob, age 6, male, younger brother.
Jane, age 15, female, older sister.


MEDICAL HISTORY

Please provide child's medical history as known.


EDUCATION HISTORY

Details about school(s) and learning skills.


ACADEMIC CONCERNS

Below is a list of concerns or problems, please check all that you feel applies to your child.


Early Development

Birth, Infancy, and Early Childhood Development History


Substances used during pregnancy

Please provide details.


EARLY BEHAVIOR

Please check all of the behaviors that best describe your child during infancy and early childhood.


EARLY EXPERIENCES

Please check all of the experiences that fit for your child during infancy and childhood.


CHILD'S TRAITS

Child’s Temperament, Traits, and Social Interactions.


Problem Areas

Please check all that apply to your child.


FAMILY TRAITS

Has your child or any of your family members struggled with any of the following?
Check all that apply.


Social Media and Technology

Sources and time your child spends on social media.


REVIEW

Please review your answers and sign this form to indicate you have answered questions to the best of your ability.


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